Part B Insider (Multispecialty) Coding Alert

Published on Fri Jun 06, 2014 PDF

Treating ‘contiguous structures’ is an exception to this well-known rule.

Modifier 59 is used so ubiquitously in Part B practices that many coders think they know all of the facts about it—but you could probably still benefit from some education on the “distinct procedural service” indicator. CMS wrote its most useful modifier 59 tips in new MLN Matters article SE1418, issued last week, so every coder can get all of the facts on its appropriate use.

Background: If you need a modifier to override CCI edits that bundle two services or procedures that were performed on the same day and you don’t already have a more descriptive modifier, such as an anatomical or bilateral modifier that is appropriate to use with your code, use modifier 59. This modifier will signal your payer that non-E/M services that are normally bundled need to be identified and paid separately in this case.

Don’t overlook: There are key points that you want to take into account in the documentation when using modifier 59. Documentation must support a different session, procedure or surgery, site or organ system, incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same medical professional. However, some of these circumstances have additional requirements. Read on to determine how to use modifier 59 appropriately.

Contiguous Structures Are Not Separate Sites

Although you can typically use modifier 59 in situations when you address separate sites, that rule does not apply when you’re treating “contiguous structures in the same organ or anatomic region,” the article notes. Instead, modifier 59 should not be used when treating contiguous structures. CMS offers the following example of when modifier 59 is inappropriately used:

Example: You perform column 1 code 67210 (Destruction of localized lesion of retina [eg, macular edema, tumors], 1 or more sessions; photocoagulation ) and Column 2 code 67220 (Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation [eg, laser], 1 or more sessions).

“CPT® code 67220 should not be reported and modifier 59 should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ,” the MLN Matters article states.

You Can Use 59 for Timed Services That Aren’t Continuous

One modifier 59 use that you may not realize is appropriate is when your practitioner performs two timed services “that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins,” CMS says in the document.

Example: Column 1 code 97140 (Manual therapy techniques…each 15 minutes) performed at 10:00 in the morning and column 2 code 97530 (Therapeutic activities…each 15 minutes) performed at 2:00 in the afternoon. 

“In this case, the procedures are performed in different encounters on the same day,” so modifier 59 is appropriate, CMS indicates in the MLN Matters piece.

Therapeutic Procedure After Diagnostic? 59 Might Be OK

You’ve probably been in situations when you performed a diagnostic procedure and the results of it prompted you to perform a therapeutic procedure. But if you immediately wrote off the diagnostic service as bundled into the second service, you could be wrong.

“Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure,” CMS says.

Example: The surgeon performs an angiography (75710), and the results prompt him to immediately perform endovascular revascularization (37220). In this situation, you can append modifier 59 to 75710 “if a diagnostic angiography has not been previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography,” CMS says in the article. 

Resource: To read the complete modifier 59 MLN Matters article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf.